Salvage Procedures of the Shoulder: Glenohumeral Arthrodesis and Resection Arthroplasty.

BACKGROUND: With the advances of modern medicine and technology there has been an increase of indications of shoulder reconstruction techniques and shoulder arthroplasty. Consequently, the number of complications and failures have increased in parallel. Not negligible number of cases are driven to an end-stage situation where salvage procedures, such as glenohumeral arthrodesis (GHA) and shoulder resection arthroplasty (SRA), are the only remaining solution. METHODS: The current literature on glenohumeral arthrodesis and shoulder resection arthroplasty was reviewed to determine the indications, surgical technique, complications and outcomes. The electronic search was conducted using the MEDLINE and EMBASE databases and the strategies used were "glenohumeral arthrodesis", "glenohumeral fusion", "shoulder arthrodesis" and "shoulder resection arthroplasty". RESULTS: Indications for glenohumeral arthrodesis (GHA) include brachial plexus injury, tumor resections, chronic infection, failed prosthetic arthroplasty, persistent refractory instability or pseudoparalysis of the shoulder with combined irreparable rotator cuff and deltoid injuries. GHA provides good stability, pain resolution, although function is markedly compromised and relying mostly on scapulothoracic joint. The gold standard surgical technique continues to be open shoulder arthrodesis and still has a high complication rate. Shoulder resection arthroplasty (SRA) indications have evolved through the years, being nowadays a salvage procedure for recalcitrant infection of shoulder arthroplasty the main indication. Shoulder function after SRA is often severely compromised, but has a high infection rate resolution. SRA is not technically demanding and complications are rare, being the persistence of infection the most common one. DISCUSSION: Despite GHA and SRA having negative connotations, in selected patients, these procedures can diminish pain, resolve persistent infections and provide an acceptable shoulder function. Hence, they should be retained as part of the treatment algorithm for complex shoulder pathology.

Atraumatic Anterior Hip Dislocation as High Grade of Hip Instability: A Case Report.

CASE: Fifty-year-old woman who presented an atraumatic anterior hip dislocation during a local traditional dance exhibition. The dislocation occurred during a dance step in which extreme hip position in extension and external rotation was held. After urgent closed reduction under general anesthesia, the patient underwent conservative management with a follow-up of 24 months. There were no further dislocation events or sequelae, with the Hip Disability and Osteoarthritis Outcome Score-12 scale score was 100 points at the end of follow-up. CONCLUSIONS: Atraumatic hip dislocation is the highest grade and exceptional presentation of hip instability and requires immediate treatment. Conservative treatment is satisfactory, although in case of recurrence or persistent residual symptoms, other treatments are warrant.

Upper Limb Lengthening in Achondroplasia Using Unilateral External Fixation.

PURPOSE: The purpose of this study was to analyze the long-term results of humeral lengthening in achondroplastic patients and make suggestions on the most appropriate surgical technique to improve patient outcomes. METHODS: Fifty-four humeral lengthening procedures performed in 27 achondroplastic patients were reviewed. Elongations were performed by means of callotasis with unilateral external fixation. Inclusion criteria were: achondroplastic patients under 17 years without prior arm operations and minimum follow-up of 36 months. RESULTS: Fifty humeri in 25 patients (13 men and 12 women), aged between 9 and 17 years, met the inclusion criteria. Mean humeral lengthening was 8.82 cm (range: 5 to 10.5 cm), which represented an elongation of 54.80% (range: 46% to 63%) of the original length. The healing index was 0.91 months (range: 0.72 to 1.4 mo) per centimeter gained. Shoulder and elbow range of motion and stability were preserved in 47 limbs. Noncomplicated cases consistently experienced a significant functional improvement in the performance of activities of daily living such as putting on footwear and personal hygiene. Short-term complications included 11 pin-tract infections, 1 radial nerve neuropraxia, and 1 failure of the regenerated bone formation. None of these complications prevented from completion of treatment. Long-term complications included 2 cases of nonunion, 3 elbow flexion contractures, and 2 cases of psychological dissatisfaction, all of them in 4 patients. Factors associated with long-term complications were intraoperative fragment displacement and distal humeral osteotomy. No fractures of the regenerated bone were identified in the long term. CONCLUSIONS: Callotasis with unilateral external fixation is a reliable and well-tolerated procedure for humeral lengthening in achondroplastic patients, with an acceptable complication rate. Guided fixator placement and a proximal humeral osteotomy are strongly recommended technical tips as they may help prevent complications and improve outcomes. LEVEL OF EVIDENCE: Level IV-case series.

Prospective study of pediatric medial humeral epicondyle fractures nonoperatively treated. Clinical, radiologic, and functional evaluation at long term.

The objective of the study is to evaluate the natural history of the medial epicondyle avulsion in children with nonoperative treatment (NOPT) on different magnitude of displacement and long-term follow-up. A prospective study of 34 patients with medial epicondyle avulsion with (NOPT) was performed. Clinical test (stability, strength, atrophy, tenderness, Tinel test, and range of motion), subjective scores [Visual Analog Scale (VAS), Likert scale, side-to-side valgus test], and objective four scores were performed. Age at the time of injury was 8.9 ± 2.81 years. Follow-up was 7 ± 2.81 years. Four of the patients had anterior displacement. Displacement varied between 3 and 26 mm (10.49 ± 6.16 mm). Subjective: VAS and ordinal three-point Likert scale were excellent. Objective results were also excellent Mayo Elbow Score: 98.67 ± 4.31 (85-100), Oxford Elbow Score: 59.35 ± 1.68 (51-100), Elbow Assessment Score System: 96.27 ± 9.77 (57-100), Disabilities of the Arm, Shoulder, and Hand (DASH) score 0.64 ± 1.001 (0-4.16). We did not find any differences in strength or forearm diameter. There was an extension deficit in seven cases with a significant association with the magnitude of displacement (P = 0.02) and with the presence of concomitant lesions or anterior displacement of the medial epicondyle >5 mm. All except one were stable clinically on valgus stress. There is a significant association between the objective outcomes (scores) and concomitant lesions but not with regards to the DASH score P = 0.102). There is no association between the magnitude of medial epicondyle displacement or the follow-up and the objective outcomes. Instability was associated with valgus stress activities. There is no association between the magnitude of displacement of the medial epicondyle or the follow-up and the objective outcomes. NOPT produces excellent subjective and objective outcomes that worsened when there were associated lesions, anterior medial epicondyle displacement, or in patients who performed activities with repeated valgus stress. Based on our study, NOPT is suitable except for Open Reduction Internal Fixation indications: absolute indications, high energy injury with associated lesions, medial humeral epicondyle fracture in the dominant elbow in patients subject to activities with chronic valgus stress, and anterior displacement.

Update on premature physeal closure. Diagnosis and treatment.

PURPOSE OF REVIEW: Premature Physeal Closure (PPC) is the most common consequence of a mostly posttraumatic, physeal injury. They are of utmost importance because they can significantly alter physeal function and lead to disorders such as limb length discrepancies and angular deformities. RECENT FINDINGS: The type of physeal fracture has not demonstrated a solid predictive value in the formation of PPC, especially in the knee where almost any type of fracture can produce it. The detection of physeal damage with imaging tests (simple radiology and MRI) is very accurate; however, their predictive capacity to foretell which injury will generate a physeal bridge is still poor. For this reason, it is not advisable to make surgical decisions at the first medical assessment. Direct surgical management of PPC's (resection-interposition technique) has generally shown high unpredictability. Nevertheless, the latest interposition materials (chondrocytes and mesenchymal stem cells) showed promising results. SUMMARY: PPC is an often devastating consequence of physeal injury and as such deserves further research. To date little is known about etiopathogenesis, risk factors and natural history among other aspects. Until direct surgery offers more consistent results, acute osteotomies and bone distraction for progressive correction continue to be the most widespread treatments for PPCs.

Infección nosocomial por Cronobacter sakazakii tras cirugía de tobillo en un paciente adulto inmunocompetente / Nosocomial Cronobacter sakazakii Infection after Ankle Surgery in an Immunocompetent Adult Patient

RESUMEN Cronobacter sakazakii es una bacteria Gram negativa que pertenece a un grupo emergente de patógenos oportunistas de la familia de los Enterococos, que causa infecciones nosocomiales. Afecta típicamente a los recién nacidos de bajo peso; puede causar graves infecciones como meningitis, sepsis o enterocolitis necrotizante, potencialmente mortales, aunque la gran mayoría de las infecciones se producen en pacientes ancianos, en los que son mucho más leves. Se reporta el primer caso confirmado de infección de herida quirúrgica en España causada por C. sakazakii en un adulto inmunocompetente(AU)

ABSTRACT Cronobacter sakazakii is a Gram negative bacterium that belongs to an emerging group of opportunistic pathogens of the Enterococci family, which causes nosocomial infections. It typically affects low birth weight newborns. It can cause serious infections such as meningitis, sepsis, or life-threatening necrotizing enterocolitis, although the vast majority of infections occur in elderly patients, where they are much milder. We report the first confirmed case of surgical wound infection in Spain, caused by C. sakazakii in an immunocompetent adult(AU)

Artroplastia de resección de hombro como salvamento para infecciones recalcitrantes: estado actual de la técnica a propósito de dos casos / Shoulder resection arthroplasty as a salvage procedure for recalcitrant infections: current state of the art regarding two cases

INTRODUCCIÓN Y OBJETIVOS La artroplastia de resección de hombro (ARH) se presenta como una técnica obsoleta y una opción no válida en la actualidad, debido a la evolución de las técnicas quirúrgicas y de los implantes. Pero, como consecuencia del aumento exponencial del uso de artroplastias de hombro, están aumentando en paralelo el número de fracasos e infecciones, con necesidad de revisión y rescate. Es por ello que, en determinadas situaciones y pacientes, esa técnica vuelve a ser una opción necesaria como salvataje, aunque tiene un alto coste funcional. El objetivo de nuestro trabajo, es presentar dos casos de artroplastia de resección de hombro como una opción válida de tratamiento en la actualidad y la revisión de la literatura. CASOS Se presentan dos casos de ARH como tratamiento de rescate, en un caso de osteomielitis crónica de cabeza humeral y un caso de infección de hemiartroplastia de hombro. Ambos pacientes se encontraban sin dolor y libres de infección con un seguimiento de más de 30 meses. En un caso la funcionalidad fue limitada con un Constant de 45 pero el otro caso la funcionalidad fue aceptable con un Constant de 67. CONCLUSIONES La ARH sigue siendo una técnica útil tras el fracaso de procedimientos de revisión, para resolver infecciones protésicas recalcitrantes u osteomielitis. Los resultados funcionales son pobres, por lo que debe reservarse para pacientes con baja demanda funcional y como salvataje, tras agotar otras opciones.

INTRODUCTION AND OBJECTIVES shoulder resection arthroplasty (SRA) is currently considered as an outdated technique, due to the advances in surgical techniques and new prosthesis designs. However, with the exponential increase in the use of shoulder arthroplasties, the number of failures and infections is equally increasing, as well as the revisions and salvage procedures. In certain situations, SRA is therefore a necessary solution, although it grossly compromise shoulder function. The aim of our study is to present two cases who underwent SRA as a valid treatment option nowadays and a literature review. CASES We present two cases of SRA as salvatage treatment. First case in a chronic humeral head osteomyelitis and second in a partial shoulder prosthesis recalcitrant infection. Both patients had complete pain relief and infection was solved with a follow-up over 30 months. In the first case, postoperative shoulder function was limited with a Constant­Murley score of 45. In the second case, function was fairly good with a Constant of 67. CONCLUSIONS SRA remains a valuable technique after the failure of revision procedures, as a salvage for recalcitrant prosthetic infections or osteomyelitis. The functional results are poor, so it should be reserved for patients with low functional demand and as salvatage procedure, after assess other options.

Lateral circumflex femoral artery false aneurysm as a complication of intertrochanteric hip fracture with displaced lesser trochanter.

We present a patient who suffered an unstable intertrochanteric hip fracture and underwent osteosynthesis with a trochanteric nail. During the postoperative period, he presented a pseudoaneurysm of the lateral circumflex branch of the deep femoral artery secondary to a displaced fracture of the lesser trochanter. With the suspected diagnosis due to indirect clinical and radiological signs and confirmation by Doppler ultrasound and computed tomography angiography, a transverse arterial embolization with resolution of the symptoms was carried out. The pseudoaneurysm of the deep femoral artery or its branches is a very rare complication after intertrochanteric hip fractures, which must be taken into account in the late appearance of edema and hematoma in the thigh and evidence of medial and superior displacement of the lesser trochanter. The diagnosis is confirmed by CT angiography and the treatment by percutaneous arterial embolization has good results without the need of excising the lesser trochanter.

One-Stage Total Knee Arthroplasty Plus Corrective Osteotomy for Osteoarthritis Associated With Severe Extra-articular Deformity.

The mainstay for treatment of articular deformity caused by advanced tricompartmental osteoarthritis of the knee is total knee arthroplasty. When this is also associated with an extra-articular deformity, this also must be compensated or corrected. In this scenario, it is essential to achieve an optimal mechanical situation by restoring the anatomical and mechanical limb axes and an adequate soft-tissue balance. These premises are necessary to relieve pain and achieve satisfactory functionality and implant survival over time. A reconstructive single-stage technique is proposed for patients with knee osteoarthritis amenable to arthroplasty and a severe extra-articular deformity, aiming at addressing both problems simultaneously.

Update on treatment of adolescent Blount disease.

PURPOSE OF REVIEW: Treatments available to correct adolescent Blount disease deformities differ in terms of features, advantages, and disadvantages. Each is indicated, therefore, for different scenarios of severity, physeal condition, and maturity. The purpose of this review is to update basic concepts, surgical treatments, and controversies concerning this disorder. RECENT FINDINGS: The cause of Blount disease is unknown although etiologic factors as morbid obesity and hypovitaminosis D are thought to be associated with it. Recently, semiinvasive techniques (guided growth) have been proposed for mild deformities but remain controversial. Osteotomies with external fixation (hexapodes) are still the most recommended corrective treatment in this condition. SUMMARY: Little is known about the origin and natural history of Blount disease. Treatment is always surgical and, given their complexity, should be preceded by a thorough analysis and planning regarding all deformities. Treatment principles are to correct the three-dimensional deformity and avoid recurrence. The choice of technique mainly depends on patient maturity and severity. Guided growth is a good choice for more immature patients with moderate deformities. Progressive correction using osteotomy or physeal distraction is indicated for patients with severe deformities and low remaining growth. The Taylor spatial frame is currently the most popular progressive correction device.

Proximal Rectus Femoris Avulsion Repair.

Proximal rectus femoris tendon avulsions are rare and occur mostly in male athletes. Currently, the standard of care for complete tendinous avulsions of the direct arm of the rectus femoris is nonoperative treatment. However, surgical repair may be considered in high-level athletes who have a high demand for repetitive hip flexion performed in an explosive manner or in patients in whom nonoperative treatment has failed. The purpose of this technical note is to describe the method for surgical repair of the proximal direct arm of the rectus femoris to its origin at the anterior inferior iliac spine using suture anchors.

Core Decompression Augmented With Autologous Bone Marrow Aspiration Concentrate for Early Avascular Necrosis of the Femoral Head.

Lack of necessary perfusion to the femoral head can lead to necrosis of the underlying bone (avascular necrosis) and result in femoral and acetabular surface changes in advanced stages. Numerous treatments have been reported in the literature, including nonoperative and surgical procedures. In addition to the standard core decompression, we describe the use of bone marrow aspirate to stimulate a healing response and bone grafting, allowing for immediate weight bearing postoperatively. The purpose of this article was to describe our method of core decompression augmented with bone marrow aspirate concentrate and bone grafting for the treatment of early avascular necrosis of the femoral head.